Wis. Stats. Chapter 45	P.O. Box 7843, Madison, WI 53707-7843 | 1-800-WIS-VETS (947-8387) | WisVets.com
VETERANS SERVICE ORGANIZATION GRANT – FEDERAL BENEFITS REPORT
The information requested on this form is authorized for collection by Ch. 45, Wis. Stats., and VA 7, Wis. Admin. Code. The information collected is used to determine eligibility for a grant authorized by s. 45.41, Stats., and administered by the Department. Failure to furnish the requested information may result in denial of eligibility for programs. Personally identifiable information collected on this form is not likely to be used for any other purpose. The Department does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or provision of services or awarding grants.
Report for the FISCAL Year	2023	; FOR	VSO
From	April 1, 2022	, to	March 31, 2023

FEDERAL BENEFITS

ACTIVITY	NUMBER	COMMENTS
1.	Power of Attorney Indicate the number of new VA Form 21-22s submitted to WDVA/Other VSOs for representation	/
2.	Disability Compensation Indicate the number of new and re-opened VA Form 21-526s, reconsiderations VA 21-526 or 21-527 or other communications submitted for compensation benefits to WDVA/VA or other VSOs
3.	Pension Indicate the number of VA Form 21-527s or other communications submitted for veterans Pension benefits to WDVA/VA or other VSO
4.	Medical Expenses for Pension Indicate the number of VA Form 21p-8416s submitted for Unreimbursed Medical Expenses for pension and death pension to WDVA/VA or other VSOs
5.	Loan Guaranty Indicate the number of Federal Home Loan applications submitted
6.	Educational Indicate the number of Federal Educational benefit applications submitted
7.	Vocational Rehabilitation Indicate the number of Federal VocRehab applications submitted
8.	Medical Indicate the number of VA Form 1010EZ forms submitted for enrollment into VA Healthcare
9.	USDVA Notices of Disagreement Indicate the number of Notice of Disagreements, VA Form 21-0958, DRO Request forms submitted to WDVA/VA and other VSOs
10.	USDVA Waiver Requests Indicate the number of requests for waivers of Federal benefits regulations submitted
11.	BVA Appeals Indicate the number of VA Form 9s submitted to WDVA/VA and other VSOs
12.	Insurance Indicate the number of applications for VA Insurance programs submitted
13.	Burial Allowances Indicate the number of applications for VA Burial Allowance submitted
14.	Flag Applications Indicate the number of applications submitted for Burial Flags
15.	Marker Applications Indicate the number of applications submitted for Burial Markers
16.	DIC Indicate the number of applications for Dependency and Indemnity Compensation, VA Form 21-534, submitted to WDVA/VA and other VSOs
17.	Survivor’s Pension Indicate the number of applications for VA Death Pension, VA Form 21-534, submitted to WDVA/VA and other VSOs
18.	Discharge Correction Indicate the number of applications for discharge upgrades submitted
19.	Miscellaneous Indicate the number of applications for other federal benefits, not listed, submitted by your office. Include types in comments

WDVA 0057D (04/23)	You can access the most recent version of this form from the WDVA

W:\Templates\WDVA_0057D-VSO-Grant-Federal-Benefits-Report.dotx	website at http://dva.state.wi.us/Pages/newsmedia/WDVAToolkit.aspx